La dialisi peritoneale oggi: indicazioni e prospettive

1. La dialisi peritoneale oggi:
indicazioni e prospettive
G. Cancarini

2. DP in Italia:
bassa prevalenza

6. Il problema degli anni ’90:
Perché la DP non aumenta ?
Il problema degli anni 2000
Perché la DP si riduce ?
DP in Italia

8. 1997
18,4 %
14,2 %

9. DP in Italia
Fattori condizionanti incidenza e prevalenza

10. Relationship between the patients on dialysis in private centres and the incidence of PD in the
different Italian regions. The percentage of patients on dialysis in a given region with respect to
the total number of patients on dialysis in Italy is given on the X-axis.
Viglino G, et al. Nephrol Dial Transplant 2007;22: 3601–3605
1) I Centri Privati non praticano DP

11. Percentage PD incidence in the 325 Italian non-paediatric public centres
Viglino G, et al. Nephrol Dial Transplant 2007;22: 3601–3605
2) Il 36% dei Centri Pubbluci non pratica DP

12. Pazienti Prevalenti Dialisi Peritoneale per Centro
23%
0 5 10 15 20 25 30 35
13GMA
13UCA
13HCA
13DXA
13AAA
13AXA
13RJA
13FHA
13CVA
13BTA
13ZCA
13ADA
13FBA
T0001
13FZA
13NUA
T0002
13QGA
T0004
13ASA
13CKA
13DXB
13FCA
13GGA
13LLA
13RGA
T0003
T0005
T0006
N° pazienti

13. Distribution of responses to the question,
“Which of the following options were initially
offered to you as possible methods of
treatment (“X” all those presented—you may
“X” more than one box).”
This study suggests that an important reason for the relatively low utilization of home
dialysis therapies in the United States arises from the inability of providers to present
chronic peritoneal dialysis or home hemodialysis as alternatives to in-center
hemodialysis or to spend enough time in explaining the treatment options to incident
ESRD patients.
Mehrotra R et al. Kidney International, Vol. 68 (2005), pp. 378–390

14. CHOICE OF THE MODALITY
PATIENT INFORMATION & INVOLVEMENT
100
20
40
60
80
0
PD HD
20
40
60
80
0
PD HD
100
INFORMATION INVOLVEMENT
84%
47%
68%
25%
(USRDS 1997 Annual Data Report)

15. Viglino G, et al. Nephrol Dial Transplant 2007;22: 3601–3605
Incidence and prevalence of PD in the various regions of Italy.
3) Esperienza in DP

16. Un problema solamente Italiano ?

17. (Blake PG, Finkelstein FO. Perit Dial Int. 2001;21:107-14.
PD PREVALENT PATIENTS
CANADA
U.S.A.
14.7
10.5
37.5
27.5

18. Prevalenti Incidenti
Mehrotra R.
Utilization of PD reached its peak in 1993 (15.1%)
and since then has been progressively declining.
Reasons for the decline in PD utilization: older age and greater comorbidity
studies showing a higher mortality with PD
adequacy guidelines
rapid expansion of hemodialysis units
increasing dominance of the dialysis chains
many training programs did not create enough time
or infrastructure in training fellows in CPD .

19. DATI DI OUTCOME

20. (Bloembergen WE et al. JASN 1995;6:177-183)
Relative
risk
of death
Patient Survival: PD vs HD
- USRDS; 170,700 patient-years -
HD
1.5
1.0
0.5
0
PD
1.19
p<0.001

21. Relative Risk of death PD:HD (95% C.I.)
As-treated analysis. Canada 1990-94
Adjusted for age, gender, race, primary renal diagnosis
PD better HD better
0.90.80.7 1 1.31.21.1
Prevalent + incident*
Prevalent only NS
Incident only*
(Vonesh EF, et al. KI 2000;57,suppl 74)
* 4 years

22. RISK OF DEATH: PD vs HD
- USRDS; 1995-1997 = 112,077 patients; follow-up: 1 year-
(from: Xue JL, et al. Kidney Int 2002;61:741-746)
Diabetics
0.90.80.7 1 1.31.21.1
RR of death
PD better HD better
Non-diabetics
model 1*
model 2°
NSmodel 1*
model 2*
* = corrected for: race, sex, age and year of start
° = model 1 + BMI, albumin, BUN, creatinine

23. RISK OF DEATH ACCORDING TO AGE AND DIABETES
- CANADIAN ORGAN REPLACEMENT REGISTER-
(from: Fenton SSA, et al. Am J Kidney Dis 1997; 30: 334-342)
0.80.60.4 1 1.61.41.2
RR of death
PD better HD better
Non-diabetics
<64 years
≥65 years
Diabetics
<64 years
≥65 years NS

24. DATI EUROPEI E ITALIANI

26. 26
**
Pazienti Incidenti 1998-2003
sopravvivenza paziente
Probabilità di
sopravvivenza
Mesi
Corrette per
Eta’
Sesso
Diabete
Cardiopatia
Vasculopatia
Esclusi i deceduti nei primi 90 giorni
p<0.01
Dialisi peritoneale
Emodialisi

27. 27

28. 28

30. Curva Kaplan-Meier sulla sopravvivenza del paziente
(analisi “intention to treat”) (1981-2006)
Osservazione totale (anni)
302520151050
100
80
60
40
20
0
p < 0.03
HD
DP
%
– Nefrologia –Brescia

31. Van Biesen W, et al. Nephrol Dial Transplant (2008) 23: 1478–1481
A first and important point is of course related to patient survival.
In Europe, the gender- and age-adjusted 2- and 3-year survival rates are 79% and
68%. More importantly, these results are equal in patients started on PD or on HD.
There is even evidence, to a large extent based on European data, that a ‘PD first’
approach can further improve outcomes.
VanBiesen W, et al Perit Dial Int 2000; 20: 375–383.
Heaf JG, et al Nephrol Dial Transplant 2002; 17: 112–117.
Van Biesen W, et al J Am Soc Nephrol 2000; 11: 116–125
Korevaar JC, et al. Kidney Int 2003; 64: 2222–2228.

32. A SECOND MATTER OF CONSIDERATION IS RELATED TO COST
In Western Europe, the highest cost of renal replacement therapies is generated by labour cost,
and the cost of the disposables is lower for patients on HD versus PD. As a final result, PD tends
to be overall more economical than HD.
Also medication, like erythropoetin, and costs for transport are lower for PD
In countries where RRT is provided by the public sector (United Kingdom and Northern
European countries), PD utilization is much higher than in those where most of the RRT
provision is in private practice with fee-for-service reimbursement, (Belgium or Germany).
The labour cost for PD is almost identical irrespective of whether 5 or 30 patients are
enrolled, as the programme can be managed by two or three nurses.
The cost per PD patient treated is thus much higher in starting centres with low patient numbers.
In contrast, the ‘real estate’ cost of an HD unit is fixed, and the cost per capita goes up as
more seats remain empty. This tends to create a vicious circle, whereby HD units try to fill
their HD seats as much as possible, resulting in a low PD utilization, making PD less
profitable and creating more of an incentive for expanding the HD programme.
Van Biesen W, et al. Nephrol Dial Transplant (2008) 23: 1478–1481

33. Età e Comorbilità

34. Age specific incidence rate in 2002,
by dialysis modality, by country
HD PD
0
100
200
300
400
500
600
0-19
20-44
45-64
65-74
75+
0-19
20-44
45-64
65-74
75+
age groups
pmarp
Belgium, Dutch sp
Belgium, Fr-sp
Greece
Spain, Val
Spain, Cat
Austria
Denmark
Sweden
UK, Sco
Netherlands
Spain, Basq
UK, Eng/Wal
Finland
Norway

35. Percentage of PD across age groups in 2002 (%),
by country
0
10
20
30
40
50
60
70
80
90
100
0-19
20-44
45-64
65-74
75+
age groups
%
Belgium, Dutch sp
Belgium, Fr-sp
Greece
Spain, Val
Spain, Cat
Austria
Denmark
Sweden
UK, Sco
Netherlands
Spain, Basq
UK, Eng/Wal
Finland
Norway

37. L’età dei pazienti dializzati aumenta progressivamente
La maggior quota di dializzati sono pazienti molto anziani
La DP potrà giocare un ruolo se riuscirà a trattare I pazienti
anziani e con comorbilità.
Possibili soluzioni:
- Famiglia: dare ai partner una quota equivalente ai costi di
trasporto dei pazienti in HD.
- Infermiere del territorio→APD
(macchine con termine automatico del trattamento ?)
- RSA: APD notturna per: - residenti
- non-residenti
- APD notturna in centri HD ospedalieri

38. L’incidenza in dialisi in Italia sembra stabile, ma sono stati
aperti nuovi centri dialisi. Questo stimola a puntare alla
saturazione dei centri HD.
Cosa succederà se si avrà una riduzione di incidenza?

40. INCIDENZA

41. Tariffe
bicHD domiciliare 103.29 €/sessione 309.87 €/settimana
CAPD 46.48 €/die 340.76 €/settimana
APD 54.74 €/die 383.18 €/settimana
bicHD CAL 129.11 €/sessione 387.33 €/settimana
bicHD Ospedal. 154.94 €/sessione 464.82 €/settimana
HDF CAL 206.58 €/sessione 619.74 €/settimana
HDF Ospedal 232.41 €/sessione 697.23 €/settimana
Dubbio:
le tariffe avvantaggiano le tecniche più costose ?

42. DP: prevalence in Toronto; 1995-2000
0
10
20
30
40
50
60
1994 1995 1996 1997 1998 1999 2000
Gouvernment supports new dialysis centres
Reimbursement: HD/DP = 7
Modality independent
capitation fee
HD AVAILABILITY & REIMBURSEMENT
%